Characteristics of Cardiac Injury in Critically Ill Patients With Coronavirus Disease 2019

Abstract

Background: Cardiac injury has been reported in up to 30% of coronavirus disease 2019 (COVID-19) patients. However, cardiac injury is defined mainly by troponin elevation without description of associated structural abnormalities and its time course has not been studied.

Research question: What are the ECG and echocardiographic abnormalities as well as their time course in critically ill COVID-19 patients?

Study design and methods: The cardiac function of 43 consecutive COVID-19 patients admitted to two ICUs was assessed prospectively and repeatedly, combining ECG, cardiac biomarker, and transthoracic echocardiographic analyses from ICU admission to ICU discharge or death or to a maximum follow-up of 14 days. Cardiac injury was defined by troponin elevation and newly diagnosed ECG or echocardiographic abnormalities, or both.

Results: At baseline, 49% of patients demonstrated a cardiac injury, and 70% of patients experienced cardiac injury within the first 14 days of ICU stay, with a median time of occurrence of 3 days (range, 0-7 days). The most frequent abnormalities were ECG or echocardiographic signs, or both, of left ventricular (LV) abnormalities (87% of patients with cardiac injury), right ventricular (RV) systolic dysfunction (47%), pericardial effusion (43%), new-onset atrial arrhythmias (33%), LV relaxation impairment (33%), and LV systolic dysfunction (13%). Between baseline and day 14, the incidence of pericardial effusion and of new-onset atrial arrhythmias increased and the incidence of ECG or echocardiographic signs, or both, of LV abnormalities as well as the incidence of LV relaxation impairment remained stable, whereas the incidence of RV and LV systolic dysfunction decreased.

Interpretation: Cardiac injury is common and early in critically ill COVID-19 patients. ECG or echocardiographic signs, or both, of LV abnormalities were the most frequent abnormalities, and patients with cardiac injury experienced more RV than LV systolic dysfunction.

Keywords: COVID-19; ECG; ICU; cardiac injury; echocardiography.

Figure 1

Line graphs showing the time course within the first 14 days of ICU stay of inflammatory parameters (A), of left ventricular function echocardiographic parameters (B), and of right ventricular systolic function echocardiographic parameters (C) in patients with and without cardiac injury. Data are expressed as median and interquartile range. Blue circles represent patients with cardiac injury (n = 30). Red circles represent patients without cardiac injury (n = 13). D = day; E = early peak velocity of the mitral flow with pulsed Doppler; e′ = early diastolic peak velocity of the mitral annulus with tissue Doppler imaging; FAC = fractional area change; LV = left ventricular; LVEF = left ventricular ejection fraction; RV = right ventricular; TAPSE = tricuspid annular plane systolic excursion; TTE = transthoracic echocardiography.

Figure 2

Bar graph showing the time course of ECG and echocardiographic abnormalities in the 30 patients with cardiac injury within the first 14 days of an ICU stay. LV = left ventricular; RV = right ventricular; TTE = transthoracic echocardiography.